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GP Grievances and Appeals Associate

Company: Rangam Consultants Inc.
Location: Newark
Posted on: August 4, 2022

Job Description:

  • Title: GP Grievances and Appeals Associate Manages resolution of (grievances) complaints and/or appeals within prescribed timeframes as mandated by the regulatory entity (State of NJ or CMS) and per designated quality standards for Government Programs Division. -Some travel may be required to clients offices (Newark, Wall, Hopewell)
    • Assesses cause(s) of complaint/appeal, conducts thorough research of issue(s), determines required course of action and final disposition.
    • Interacts with relevant parties to facilitate timely and accurate complaint/appeal resolution.
    • Authorizes administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels so as to bring closure to the complaint/appeal.
    • Contacts relevant parties to acknowledge receipt of the complaint/appeal and uses probing techniques to clarify open issues, obtain additional relevant information and/or secure records necessary to complete investigation and bring issue to final resolution.
    • Review business team representative/vendor representative telephone calls with customers to verify accuracy of information related to complaint/appeal.
    • Develops customized, timely, accurate, detailed correspondence, for delivery to relevant parties, detailing case and final resolution.
    • Correspondence may be used to educate parties on benefit plan provisions and/or application of plan guidelines.
    • Responds to regulatory entity or members/providers, both verbally and in writing, regarding issue details and final determination made by Client to close the complaint/appeal.
    • Each response must be customized to the specific situation and address all issues presented by the member/provider.
    • Collaborate with internal supporting departments to review and finalize complaint/appeal determinations.
    • May prepare materials for and may attend case study meetings facilitated by designated internal or external parties.
    • Other duties as assigned.Education/Experience:
      • College degree in Journalism, Communications, or related field, or equivalent in experience.
      • Requires five years of business experience which must include two+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
      • Experience in claims processing necessary.
      • Ability to navigate the various claims and service operations systems.
      • Healthcare industry experience helpful.Knowledge:
        • Knowledge of medical insurance claim processing and membership systems preferred.
        • Knowledge of medical terminology, COB, Medicaid/Medicare procedures preferred.
        • Knowledge of Facets or Ncompass preferred.
        • Knowledge of Claims Policy guidelines preferred.
        • Excellent knowledge of Microsoft Office Suite required.Skills and Abilities:
          • Requires the ability to understand and use language correctly, to be determined by the Language skills test.
          • Requires keyboarding proficiency.
          • Requires the ability to perform basic arithmetical calculations.
          • Requires the ability to read, understand and interpret written materials.
          • Requires the ability to apply reason in order to determine the appropriate arithmetical operation for solving a problem.
          • Requires the ability to analyze information and to understand and apply rules and procedures.
          • Requires the ability to compose business letters.
          • Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder.
          • Must be able to detail member-specific issues through the development of individual correspondence for each case, explaining all issues in a comprehensive, understandable fashion.
          • Requires strong telephone/interpersonal skills, strong conflict resolution skills and the ability to remain professional during difficult interactions with customers.
          • Excellent interpersonal skills (i.e. active listening).
          • Strong research, investigative, analytical, decision making and problem solving skills.
          • Ability to perform in high pressure situations.
          • Ability to multitask.
          • Ability to manage and diffuse irate callers.

Keywords: Rangam Consultants Inc., Newark , GP Grievances and Appeals Associate, Other , Newark, New Jersey

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